key: cord-0938050-apyecvtm authors: Durdella, Haley; Everett, Scott; Rose, Jerri A. title: Acute phlegmonous gastritis: A case report date: 2022-02-28 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12640 sha: 2c0c9570a374c6e16b9859a1aaed035462da320a doc_id: 938050 cord_uid: apyecvtm Acute phlegmonous gastritis (APG) is an extremely uncommon and potentially rapid fatal systemic infection with very few reported cases in the literature. This case report demonstrates a case of idiopathic APG in an afebrile, otherwise healthy individual that resolved with broad‐spectrum antibiotic therapy and did not require operative management. Acute phlegmonous gastritis (APG) is a rare and often fatal disease. Symptoms can be non-specific. Patients typically present with abdominal pain, nausea, vomiting, fever, and signs of infection. 1 The most common pathogens related to APG described in the literature are the Streptococcus species. 1, 3 Although the pathogenesis is not completely known, predisposing factors-including mucosal injury, immunocompromised state, chronic alcohol use, underlying gastric malignancy, and a history of gastritis-have been hypothesized as contributing to this condition. 2 However, approximately half of patients who develop APG were previously healthy. 3 Because of its rarity, best practices for treatment are poorly understood, making management decisions difficult. We present a case of APG affecting an afebrile Supervising Editor: Kenneth Katz, MD. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Before the onset of her symptoms, the patient was in good health. Her past medical history included psoriasis (requiring only topical medications) and a remote stress fracture of her right femoral neck that had healed with conservative management. Her history was negative for recent surgeries. Other than a topical corticosteroid for psoriasis, the patient reported taking no home medications or supplements. Social history was negative for tobacco use, illicit drug use, and alcohol abuse. The patient reported being married with 2 children at home, and she was working full time as a physician. She had not traveled recently. On presentation to the ED, the patient appeared uncomfortable but non-toxic. Her initial vital signs were temperature 98.6 • F; heart rate 63 beats per minute; respiratory rate 16 breaths per minute; blood pressure 151/94 mm Hg; and pulse oximetry 99% on room air. The patient was alert and fully oriented. Her physical examination was pertinent for significant tenderness to palpation over the epigastric region of her abdomen, without abdominal rigidity, rebound, or guarding. An initial evaluation, including complete blood count with differential, serum lipase, comprehensive chemistry panel with liver function tests, polymerase chain reaction testing for COVID-19, electrocardiogram, chest radiography, and a bedside point-of-care ultrasound of the abdominal right upper quadrant, was unremarkable with no acute abnormalities. Given the severity and persistence of the patient's epigastric pain and nausea, computed tomography (CT) imaging of the abdomen and pelvis with intravenous contrast was obtained, revealing mucosal enhancement with significant submucosal edema at the gastric body and edema within the soft tissues along the lesser curvature of the stomach, concerning for APG ( Figure 1 ). Evaluation with upper endoscopy to exclude underlying neoplasm was recommended. After the patient's case and imaging study were reviewed with the general surgery and gastroenterology physicians at the community hospital where she presented, she was transferred to an ICU at a nearby tertiary center for further care, given the potentially aggressive course of APG and high concern that the patient could acutely decompensate. Broad-spectrum antibiotic therapy with intravenous piperacillin-tazobactam and fluconazole was initiated before transfer; the patient was also started on intravenous fluids and was directed not to take any fluids or food by mouth. Broad-spectrum antibiotic therapy with intravenous piperacillintazobactam and fluconazole-along with pantoprazole-were continued throughout her hospital course in the tertiary care center ICU. She remained afebrile and hemodynamically stable. Her epigastric pain and nausea improved rapidly after initiation of intravenous antibiotic therapy. By the patient's second hospital day, her epigastric discomfort was minimal, and her nausea had resolved. Repeat CT imaging of the abdomen and pelvis-obtained approximately 48 hours after the patient's initial imaging study-showed a significant interval decrease in gastric body submucosal edema compared to that seen on her prior examination ( Figure 2 ). Given her significant clinical and radiographic improvement, the patient was allowed to begin a clear liquid diet, which she tolerated well. She was discharged home with directions to complete a 2-week course of oral amoxicillin-clavulanate and fluconazole, along with oral pantoprazole twice daily. She was scheduled to return for an esophagogastroduodenoscopy (EGD) procedure 2 weeks after hospital discharge rather than undergoing EGD during her hospitalization, given the gastroenterology team's concern that she was at higher APG has been reported in all age groups, most commonly in adults in their 50s to 70s, with a 2:1 male-to-female ratio. 1 Although the eti-ology is not fully understood, bacterial invasion of the gastric wall into the submucosa seems to be the primary pathophysiologic mechanism. to the fact that the diagnosis is often delayed or missed. Before the advent of antibiotics, the mortality rate exceeded 90% for this condition; with antibiotic therapy, the mortality rate has decreased to around 48%. 3 For patients in whom antibiotic therapy is ineffective, surgical intervention is required. Abdominal CT is helpful for both prompt diagnosis of APG and detecting associated complications. Characteristic CT findings of this condition include thickening of the gastric wall, low-intensity areas within the gastric wall (indicative of abscess), and gas accumulation. 1,3 APG is a rare condition associated with high morbidity and mortality rates. Although this condition most commonly affects patients with underlying chronic conditions, it can also affect healthy individuals. 3 Although fever has been a key presenting feature in previously reported cases of APG, the case we report involved a healthy female presenting with severe epigastric pain, nausea, and anorexia, without documented fever (although subjective fevers at home were reported), leukocytosis, or other signs of infection. A high index of suspicion is required to make this uncommon diagnosis in a timely manner. Because Diagnosis and treatment of acute phlegmonous gastritis Acute phlegmonous gastritis Acute phlegmonous gastritis Acute phlegmonous gastritis: A case report